Thyroid Cancer Surgery

Thyroid Nodules and What They Do — and Do Not — Mean

The thyroid is a butterfly-shaped gland lying in the front of the neck, just ahead of the windpipe. It produces the hormones that set the body's metabolic pace. A discrete lump that forms within the gland is called a nodule. Nodules are common, become more common with age, and are very often discovered by chance on a scan requested for something else entirely, in someone with no symptoms at all.

The essential point is this: the great majority of thyroid nodules are benign. Finding one is not a diagnosis of cancer — it is the beginning of an assessment. Where thyroid cancer is present, the commonest forms are typically slow-growing and are managed in a planned, unhurried way. Our aim at İzmir Cerrahi Merkezi is to assess each patient properly, to avoid operating when an operation is not needed, and — when surgery is indicated — to perform an operation of the right extent for that individual.

Symptoms and Reasons to Have a Nodule Assessed

Thyroid nodules and early thyroid cancers usually cause no symptoms whatsoever. Thyroid hormone levels are generally normal, so the absence of complaints such as palpitations, weight change or fatigue tells you nothing about whether a nodule is present. When symptoms do appear, they are not specific to cancer; the same complaints arise from benign enlargement and multinodular goitre.

Even so, the following situations warrant assessment by a general surgeon or an endocrinologist. Hoarseness lasting more than a few weeks, and a neck swelling that is visibly enlarging, should always be explained rather than watched.

• A new or growing swelling in the front of the neck
• Hoarseness persisting beyond a few weeks
• Difficulty swallowing, or a sensation of pressure or catching in the throat
• A neck lymph node that can be felt and does not settle
• A family history of thyroid cancer, particularly medullary thyroid cancer
• Radiotherapy to the head or neck in childhood or adolescence

How a Thyroid Nodule Is Investigated

Assessment usually begins with two things: a TSH blood test and a thyroid ultrasound. TSH indicates whether the gland is under- or over-active. Ultrasound describes the nodule in detail — its size, whether it is solid or cystic, the regularity of its margins, the presence of microcalcifications and its blood flow — and, just as importantly, examines the lymph nodes of the neck. These features are scored using recognised risk-stratification systems such as TIRADS, and it is that score, together with size, that determines whether a biopsy is needed. A radioisotope scan is not routine; it is generally reserved for patients whose TSH is low.

When biopsy is indicated, the test performed is fine-needle aspiration biopsy. Under ultrasound guidance, a needle finer than the one used to take blood samples is passed into the nodule to collect cells. It takes a few minutes and requires no hospital admission. The pathologist reports the sample using the Bethesda system — a shared vocabulary between pathologist and surgeon rather than a verdict in itself.

• Non-diagnostic: too few cells to assess; the biopsy is repeated
• Benign: no operation required; the nodule is followed with ultrasound
• Atypia of undetermined significance: repeat biopsy, molecular testing or close surveillance is considered
• Follicular neoplasm: benign and malignant cannot be told apart on cells alone, so diagnostic lobectomy is often advised
• Suspicious for malignancy and malignant: surgery is planned

Types of Thyroid Cancer and the Extent of Surgery

Thyroid cancer is not a single disease. Papillary carcinoma is the most common type and is usually slow-growing. Follicular carcinoma is less frequent and often cannot be distinguished from a benign follicular adenoma until the removed tissue is examined under the microscope. Medullary carcinoma arises from the calcitonin-producing C cells, may run in families, and prompts genetic assessment. Anaplastic carcinoma is rare, behaves aggressively, and requires prompt multidisciplinary management.

The central surgical question is whether to remove only the affected half of the gland — a lobectomy — or the whole gland, a total thyroidectomy. A small, single-focus tumour confined within the gland may be adequately treated by lobectomy, which leaves some prospect of avoiding lifelong hormone tablets. Where lymph nodes are involved, a central compartment or lateral neck dissection is added according to where the disease sits. Neck dissection is not performed as a matter of routine in every patient; it is planned when involvement has been demonstrated on imaging or biopsy. The decision is individual and can only be made after examination and review of the investigations together.

• Tumour size and whether disease is single- or multi-focal
• Whether the tumour extends beyond the thyroid capsule
• Whether neck lymph nodes are involved
• Whether suspicious nodules are present in the opposite lobe
• Histological subtype — total thyroidectomy is standard for medullary cancer
• Family history of thyroid cancer or previous neck radiotherapy
• The patient's general health, preference and ability to attend follow-up

The Voice Nerve and the Parathyroid Glands

Almost every patient asks about the voice first. The recurrent laryngeal nerve, which moves the vocal cords, runs upward in the groove between the windpipe and the oesophagus, immediately behind the thyroid. Its closeness to the gland is a fact of anatomy, not bad luck — which is precisely why identifying and preserving it, under direct vision, is one of the defining steps of the operation. Intraoperative nerve monitoring may be used where appropriate. In the weeks after surgery, swelling or traction on the nerve can cause temporary hoarseness or a voice that tires quickly; this is usually transient and settles.

The second question is about calcium. The parathyroid glands — usually four, each about the size of a grain of rice — sit against the back surface of the thyroid and regulate the calcium level in the blood. During surgery they are left in place with their blood supply intact wherever possible; if a gland's blood supply is compromised, it can be autotransplanted into neck muscle. Calcium may nonetheless dip temporarily afterwards, causing tingling around the mouth and in the fingertips or muscle cramps. It is monitored with blood tests and supported with calcium and vitamin D, and in most patients it is temporary. No operation is free of risk, and these considerations are discussed individually before surgery.

Recovery, Thyroid Hormone and Long-Term Follow-Up

The operation is performed under general anaesthesia through an incision placed in a natural skin crease at the front of the neck. Most patients stay one night, though this depends on the extent of surgery and on the individual. Discomfort is generally mild and manageable with simple analgesia; some tightness in the neck and mild discomfort on swallowing in the first days are expected. Return to work is commonly within one to two weeks, but this varies.

The pathology report on the removed tissue usually takes a few days to a week. It is then reviewed together with endocrinology and, where relevant, nuclear medicine, taking into account the tumour type, size and spread. For some patients the next step is radioactive iodine; it is not required for everyone, and that decision belongs to the multidisciplinary team rather than to any single doctor. Surgery is one component of care, not the whole of it.

After total thyroidectomy, thyroid hormone replacement is lifelong. It is best thought of not as a burden but as a straightforward daily commitment: one tablet each morning on an empty stomach, with the dose adjusted to you on the basis of blood tests. After lobectomy, some patients need replacement and others do not, and blood tests will show which. Follow-up combines TSH with tumour markers appropriate to the cancer type — thyroglobulin, or calcitonin in medullary disease — and periodic neck ultrasound. Please contact your doctor promptly if any of the following occur after surgery.

• Tingling around the mouth, in the hands or feet, or muscle cramps
• Marked or persistent hoarseness, or difficulty breathing
• Rapidly increasing swelling, firmness or bruising in the neck
• Redness, discharge or fever suggesting a wound problem
• Any uncertainty about your tablets, blood tests or follow-up appointments